This article aims at giving a broad overview on competency-based education to those who are currently in the predominantly knowledge focused discipline-based curriculum and so are uninitiated to the competency-based educational paradigm. This is done by taking them through the curricular trends in medical education that have happened elsewhere in the world and providing them with a gist of what is competency-based medical education, how it is different from the earlier paradigms of instruction, the advantages that this paradigm of mastery learning presents to help the learner acquire competencies needed for doing the professional tasks and duties that are in alignment with health needs of the country, the framework and the broad steps involved in its implementation, the challenges that its implementation presents particularly with regard to benchmarking for assessment as revealed by the experiences in the Western world that resulted in a three-decade lag between intention to change and actual change and the way forward to overcome these challenges particularly through faculty capacity-building using longitudinal faculty development programs or series of faculty retreats to ensure that it can be successfully implemented and sustained to serve the purpose of producing job-ready professionals.

Medical Education in this part of the developing world is waking up to the reality that there is a need for change from the currently mostly knowledge-based education, to focus on skills that are needed to perform duties as a health care professional. This is mainly because, the knowledge base has expanded exponentially through gains in scientific facts or new knowledge expedited by the tools now made available in this information technology age. Hence, as a result of this, what is new knowledge becomes obsolete in a shorter period of one's lifetime. Compounding this is the fact that in this information technology world, it is easier to get information you want and so the need to remember lot of things is no longer as important as it used to be than knowing how to get the information you need and use it for problem solving which is often required in health care delivery. In the developed world, this has led to changes in medical education with emphasis shifting from teacher-centered (cognition or knowledge transfer by teacher) to student-centered (ensuring learning by students and equipping them with meta-cognition, i.e., how to learn) and from discipline-based (knowledge dominant teaching of individual disciplines in water-tight departments) to integrated learning (system-based or organ-based) to problem-based learning (the health problem triggering and motivating the student to learn what they need to learn to solve the problem to improve health) so that in an Information Technology user-friendly world, the health care provider is equipped with skills to enable them to solve real-life problems in the hospital or the community. This led to the focus shifting to development of competencies needed to carry out the professional tasks.

The Lancet Commission's report [1] studying the past reforms in medical education and the needs of the health professionals education to prepare them for the 21 st century's health systems describes these changes in terms of three generation of educational reforms starting from informative (with focus on information plus skills to produce "experts") moving on to formative (focus on socialization and values to produce "professionals") to transformative (with focus on leadership attributes to produce "change agents"). They along with the World Health Organization (WHO) initiative [2] recommended the need for Health Professions Education to not only be competency-based to produce competent professionals who could carry out the tasks their duties require them to do to fulfill health care needs of the people they serve but also for them to be transformative leaders of health teams who can work effectively together in teams that deliver health care. This requires doctors to have leadership competencies so that they can become effective change agents [Figure 1] to transform the way the health care is delivered by a health care system team they would be leading.

Figure 1: Trends and change in focus in Medical Education across the World

This article aims at giving a broad overview on competency-based education to those who are currently in the predominantly knowledge focused discipline-based curriculum and so are uninitiated to the competency-based educational paradigm. This is done by taking them through the curricular trends in medical education that have happened elsewhere in the world and providing them with a gist of what is competency-based medical education, how it is different from the earlier paradigms of instruction, the advantages that this paradigm presents to the learner in health professions education institutions, the broad steps involved in its implementation, the challenges that its implementation presents and the way forward to overcome these challenges to ensure that it can be successfully implemented and sustained to serve the purpose of producing job-ready professionals.

Competence, Competency, Capability and Competency-based Education

Competence means the acquisition of sufficient knowledge, psychomotor, communication and decision-making skills, and attitudes to enable the performance of actions and specific tasks to a defined level of proficiency. [3] Describing it in the professional clinical context Epstein and Hundert [4] defined it as "the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual, and the community being served." Whereas the words competency and competence are often used interchangeably in the literature, the term competency is used for the skill itself and competence as an attribute of the performer's ability to perform the skill.

Fraser and Greenhalgh [5] recommended that in the present complex changing world, there is a need to move beyond competencies to capabilities. Here, capabilities reflect the extent to which individuals can adapt to change, generate new knowledge, and continue to improve their performance.

That competency-based medical education is different from subject-centered and integrated curricular models in three fundamental ways was brought out well by McGaghie etal. [6] First, it is organized around functions or competencies; second, students can all be trained to master prescribed basic performance objectives and third, they can be measured or tested to see whether they have reached the defined level of proficiency as a health professional. They also reiterated that in competency-based curriculum, the premise is that the many roles and functions involved in the doctor's work can be defined and listed clearly and that this can be dismantled into smaller cumulative steps through which students may work at individual rates of progress through deliberate practice and formative feedback till they reach the desired level of proficiency or expertise. We can also call this type of learning as "learning for mastery."

Distinguishing Features of Competency-based Education

Those who are products of the traditional system of medical education often ask why have curricular reforms and change to competency-based medical education if the knowledge focused traditional system can produce doctors that are doing well all over the world (why fix it if it is not broken?). The protagonists for change counter by saying that this is the wrong question to ask, the right one being to ask through impassioned self-assessment "does the current one deliver the best possible education given the rapid obsolescence of new knowledge, rapidly changing disease pattern due to rapid epidemiologic and demographic transition of world's population and advances in health care?" In the traditional approach to education, the teachers determine what contents need to be learned by the student, they then teach it and then test the students to see if the content was learned by students. Research in medical education has supported the need to shift to the competency based one where there is alignment of training and learning with outcomes and assessment of health professionals' performance in relation to specific and real work conditions on professional expectations in real work settings (Association for Prevention Teaching and Research). [7] Carraccio etal. [8] captured the essence of the differences between the two paradigms of education namely the structure- and process-based one and competency-based education (Table 2).

A competency focuses on the performance of the end product or the goal state of the instruction

It uses a standard for judging competence that is not dependent on the performance of other learners

A Competency informs learners as well as other stakeholders about what is expected of them

It is self-regulated with flexible learning options in terms of time and sequence of what is to be learned by the learner.

Advantages of competency-based education

Sullivan [10] summarized the advantages of competency-based education by stating:

The primary advantage is that the focus is on success of each participant by ensuring they achieve competencies required in the performance of their jobs. Other advantages include:

Being focused on learning for mastery of specific skills, it builds their confidence in being ready for the job.

Training time is used more effectively and efficiently as the trainer is facilitator of learning as opposed to a provider of information.

Gruppen etal. [9] also highlighted the beneficial role competency-based education can play in improving Global Health particularly in resource-poor settings. This is because competency-based education is more focused and tailored to achieving competencies the graduates would need to discharge their professional duties as health care professionals. This forces the curriculum planners to discuss and identify what competencies are needed to address the priority health care needs of the country. Once the list of competencies needed for health care of the people is arrived at, it helps academic policy makers and planners to consider whether some of these can be "task shifted" to other health care professionals rather than loading only doctors. Furthermore, competency-based education besides ensuring clinically competent professionals also focuses on leadership and thereby helps them to be job-ready to function effectively in the health system which in resource-poor settings badly needs capable leadership inputs to ensure policy formulation, effective management, and the direction of interdisciplinary teams.

Implementing Competency-Based Curriculum

One of the earliest treatises that are available in the literature on competency-based education is the one by McGaghie/WHO [6] and it provides the framework for the steps to be taken in implementing competency-based curriculum:

Identifying the elements of competence:

Analysis of physician's activities through self-reports, observation, and task analysis.

Critical elements of behavior for capturing qualitative dimensions of care through critical incident study to distinguish between poor and good professional performance of the task.

Health care needs determine the competencies needed and are identified from public health statistics of the country and medical records.

Learning for mastery:

Time self-paced by the learner's need for mastering the competencies.

Program organization: The sequencing of competencies and their learning experiences,

Program organization for mastery:

Specification of learning objectives.

Development of instructional units.

Encouragement of self-pacing.

Recognition of competence levels.

Frequent assessment of learning.

Assessment of competence:

Entry level assessment - assessment of the baseline level and readiness for further learning.

Formative assessment - assessment of what has been learned and what remains to be learned.

Summative assessment - assessment of attainment of the required level of competency.

Preparation of teachers, students, and institutions for the:

New educational roles of the teacher.

Focus shifts from teaching to facilitator of student learning.

Teachers need to engage in continuing professional development.

Teacher as a planner.

Defining the competencies and the levels of to be attained.

Do planning of learning experiences for the student to learn and the sequencing of these to ensure achievement of competency progression.

Teacher as a manager of instructional resources.

Teacher as a performance assessor to test student's attainment of the expected level of competency and evaluator or effectiveness of educational learning experiences.

New educational roles of the student:

Take personal responsibility for learning instead of passive listening and learning.

Carraccio etal. [8] reviewed implementation of competency-based education in various centers around the World and reported that a stepwise approach to curricular design was adopted most often. The four major steps that were common across most centers were the following and a brief note by them about how to go about it is helpful for better understanding to facilitate implementing each step:

Identification of competencies - using a Delphi technique for consensus of individual experts; use of nominal group technique for obtaining group consensus; task analysis by investigator through observation of professionals on-the-job; critical incident survey and behavior-event interview of a "star performer" to identify good and bad practice, etc. and the simplest one being practitioners survey

Determining the components of the competency and the expected performance levels . The competency components include professional tasks which either sequentially or in sum to make up the competency. The tasks serve as performance indicators or benchmarks which must be measurable in the aggregate determine achievement of a competency and performance criteria set the threshold for demonstrating competence. The expected performance level for each benchmark must then be defined to determine whether competence has been achieved.

Assessment of the competency . The preferred method for this is use of criterion-referenced measures that compares performance against set standards or threshold; Shumway and Harden [11] have reiterated in their AMEE Guide on outcomes assessment of competency, various methods and tools to make measurement of "shows how" (clinical and practical assessment) and "does" (observation, portfolios, logs, peer assessment) levels within the Miller's pyramid of learning assessment. Norcini and MacKinley [12] have given a more detailed practical overview on issues and newer measurement tools used in performance-based clinical assessment including use of a framework for selection of the assessment method. Norcini and Burch [13] have emphasized the important role of formative assessment and feedback as well as various tools that have been found useful for this at the workplace for performance assessment and so are useful for measuring and documenting evidence of competency progression and so is a useful resource for reference while planning and implementing assessment of competency in your institution; and

Overall assessment of the process (process evaluation) . This helps the program implementers to identify processes that are amenable for further improvement to make the process more efficient.

Challenges in implementing competency-based education and the way forward

Simply having the intention to move from traditional teaching to competency-based education is not enough. There are several challenges that need to be overcome before it is possible to start implementing it in your institution. This was observed even in the most favorable educational environments in the developed world. Carraccio etal. [8] reviewing literature observed a three-decade lag period between acceptance and actual implementation of competency-based education and identified the following challenges that explained the delay. Anticipating these challenges in countries where the paradigm shift toward competency-based education is on the anvil, possible solutions and the way forward to overcome these are suggested based on recommendations that emerge from the literature review:

Benchmarking for assessment

The lack of awareness about the need as well as the required knowhow about benchmarking of assessment was one of the main obstacles to effective implementation and institutionalization of competency-based education. This is a very critical hurdle to overcome since without this benchmarking of the competency and its expected level, it is difficult to develop strategies and learning experiences, as well as design tools appropriate for its assessment. This important step toward shift to competency-based education involves detailed benchmarking of specific competencies and decisions regarding how to attain them or the modalities for assessment of attainment of developmental milestones in the competency progression during the course as well as the attainment of predetermined benchmarked level of competence indicating the end of the course.

Coordinating medical student and PG/residency program

Benchmarking also needs to be done regarding the levels to be attained during each of these phases of professional qualification and development. [14] We generally expect the competency level at the medical school graduation level to reach the benchmarked "advanced beginner" (or the "shows how" performance level of the Miller's learning assessment pyramid) for most competencies and to the "competent" level of dreyfus for some critical ones and from there after graduation during PG/ Residency program striving for competency progression toward "proficient" level for most and "expert" level for many critical ones.

Expanding programs for faculty development

Teachers are mostly ill-equipped to implement competency-based curriculum unless they themselves were a product of it. Building their capacity is an essential prerequisite before any attempt to implementing it can be attempted. The areas where teacher's capacity building needs to be addressed include all essential elements of curriculum design starting from identifying the needed competencies based on the profile of professional job duties, their performance expectations, and measurement criteria in all relevant domains including communication and analytical skills to design of the learning experiences for deliberate practice and design and use of performance assessment tools and giving feedback to the learner besides benchmarking the exit-level competencies. Sullivan [10] cautioned that the challenge posed by new skills-set needed for implementing competency based education leads to the tendency of teachers slipping back to "teach as we were taught" and so there is need for longitudinal programs in faculty development [15] which have a series of learning experiences including application of learning to work situations that are tailored to address specific teaching skills for competency development including teaching for leadership development make them a "proficient teacher" [16] with follow-up assistance and periodic hand-holding workshops and mentoring for the teachers to learn from the success of others and discover ways to overcome the problems faced by them. Benor [16] also recommended that such teachers be certified and accredited by external accreditation agencies to ensure quality assurance of the teacher training program as well as the teacher who gets trained at these centers.

Creating better systems of student assessment

Since the focus of competency-based education is learning for mastery of skills by each learner, the process of formative assessment needs to be scheduled more frequently. An assessment blueprint which links the expected exit outcomes and competencies (derived from future professional roles and tasks/activities) to the tools for performance assessment and schedules for the formative assessments linked to planned learning experiences of deliberate practice and feedback on competency development and progression leading to attainment and testing of expected exit competencies through a summative performance assessment system needs to be prepared and administered. Boateng etal. [17] found that by doing this type of blueprinting using an outcomes-based assessment rubric helps in ensuring that assessment is coherent and consistent for all residents, measuring resident outcomes based on real-life criteria, providing opportunities for residents to demonstrate proficiency in a specific competency and outcome level, and improving the quality of assessment. To produce a "job-ready" professional, Ten Cate [18] proposed the need for identification of Entrustable Professional Activities (EPAs) which are descriptors of work (while competences are descriptors of physicians) since trust is a central concept for safe and effective health care. These are "not an alternative to competencies, but a means to translate competencies into clinical practice. EPAs usually require multiple competencies in an integrative holistic manner. An EPA must be described at a sufficient level of detail to set trainee expectations and guide supervisor's assessment and entrustment decisions." When competencies are put together as EPAs, the clinicians find it easier to relate with them since they are descriptors of their regular work and so the learning program becomes easier to get their "buy-in."

The resources needed for the competency-based educational paradigm are different from the ones traditionally needed in the content/information predominant discipline-based curricula that exist in medical schools in the developing world. Resources are mainly needed to help students engage in self-directed learning (library/on-line access), skills learning through deliberate practice with feedback or reflection on practice and observation of performance in skills labs, simulated patients and real patients at the workplace/teaching hospital. This paradigm also needs teachers with capabilities to function as facilitators of mastery of skills and assessors of attainment of skills through observation of performance.

Infrastructure for processes needed

Since competency-based education involves a shift from passive to active learning, as mentioned above, the infrastructure needed for this is different. This means that the Institutions' administrators need to be convinced about the advantages to the institution that accrue from speedy implementation of the new competency-based curriculum in terms that they understand best, that is, return on investment (to provide the needed infrastructure for learning and assessment, capacity-building of faculty, etc.) in terms of recognition and demand for admission to institutions that produce competent doctors and have a higher probability of passing the national level licensing or exit examination:

Change in teacher and student/learner ethos

For socialization into the new paradigm, Sullivan [10] cautioned that the potential obstacles that come in the way of introducing competency-based education in an institution that was on traditional teaching-learning format makes the teachers slipping back to "teach as we were taught" and so we need to anticipate this and conduct follow-up capacity building workshops in the form of faculty retreats away from routine clinical work so that they can reflect upon their own strengths, the benefits of the competency-based curricular approach, identify the challenges faced and through appreciative inquiry find out what works and so can be replicated by others within the institution. For this faculty retreat where we expect teachers to socialize and learn from each other's application of learning, we could use an article by Yelon et al. [19] for group-discussion during the retreat to overcome obstacles to transfer of learning from the faculty development program they underwent. Feedback by students and their reflections on their learning experiences as recorded in their reflective portfolio during such retreats would help the teachers and the students to socialize into the new paradigm and thus ensure that the momentum of change is sustained.

To summarize, competency-based education is more efficient than the traditional informative models of education since it focuses on "mastery learning" to help the learner acquire competencies needed for doing the professional tasks and duties that are in alignment with health needs of the country. This can be achieved through a systematic process of curriculum planning which helps the learner to go through a series of planned learning experiences that provide series of opportunities to engage in deliberate practice and receive formative feedback, document progress in mastery of skills for competency progression up to the level that the student upon graduation would be job-ready for the tasks and responsibilities that would be entrusted to her/him. The main hurdles for implementation are the lack of awareness about the need as well as the required knowhow about benchmarking of assessment, the need for change in teacher and learner ethos and garnering resources for the learning resources needed for the competency-based learning paradigm. And these obstacles can be overcome mainly through faculty capacity-building so that they become familiar with the new learner-centered ethos through a series of faculty-development retreats or a formal longitudinal faculty development program which facilitates the faculty to learn on-the-job the skills needed for this type of educational paradigm.

A crossover comparative study to assess efficacy of competency based medical education (CBME) and the traditional structured (TS) method in selected competencies of living anatomy of first year MBBS curriculum: A pilot study